12200 Park central drive suite 110 Dallas Texas 75251
THE WELLNESS LOUNGE COVID-19 TESTING CONSENT
Please read and complete the form
DATE OF BIRTHDAY
HISPANIC / LATINO NOT HISPANIC / LATINO
INSURANCE COMPANY NAME
MEMBER ID #
Informed Consent for COVID-19 Testing
Please carefully read the following informed consent:
I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nas pharyngeal swab, as ordered by an authorized medical provider or public health official.
I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others.
I understand that I am not creating a patient relationship with THE WELLNESS LOUNGE by participating in testing. I understand the testing unit is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate
action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
I understand that, as with any medical test, there is the potential for false positive or false negative test results.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19.
RELATION TO PATIENT
I read General Consent for Care and Treatment Consent and authorize the wellness lounge to use these informations to contact me by phone or email.
➔ General Consent for Care and Treatment Consent Form
➔ Patient Consent for Financial Communications Form
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